First Name

Address

Date of Birth

Is it safe to write to you? Is it safe to write to you? Yes No

Can you provide Safe Contact Details? These should be details the person using abusive behaviours has no or limited access to. Can you provide Safe Contact Details? These should be details the person using abusive behaviours has no or limited access to. Yes No

Safe Telephone Number

Safe Email Address

Safe Days to Call Safe Days to Call Monday Tuesday Wednesday Thursday Friday

Safe Times to Call: Safe times include those when you can answer the call when the person using abusive behavior towards you is not around. For example when you or they are at work, running regular errands, or at other regular appointments.

Is it safe to leave voicemail? Is it safe to leave voicemail? Yes No

Is it safe to text you? Is it safe to text you? Yes No

Is it safe to send you emails? Is it safe to send you emails? Yes No

Communication Needs: Please specify any assistance you may need to communicate with our team E.g hearing impaired

Do you require an interpreter? Do you require an interpreter? Yes No

Which language?

Reason for referral: Please can you tell us your current situation. What is happening to you and how this is affecting you? What are your main concerns at the present time? Please detail as much as you can as this will help us when we contact you. Common abusive behaviors include: Mocking, humiliation, insults, criticism | Being checked up on, followed, or stalked | Pressure, threats, intimidation, or violence | Destruction of their possessions | Isolation from family and friends | Being forced into sex | Having money taken or controlled | Lying, blame and denial of the abuse

Are there children in the household? Are there children in the household? Yes No

Are the police involved? Are the police involved? Currently Historically No

Are you referring someone else? Are you referring someone else? Yes No - I am referring myself

Your Name

Your email address

Your telephone number

If you are a professional, please tell us which organisation you work for